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Deep vein

thrombosis

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Semisolid coagulum within fowing blood invenous system

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Patient actorsAge

Obesity

Varicose veinsImmobility

Pregnancy   Puerperium

High-dose oestrogen

therapyPrevious V! or P"

 !hrombophilia

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iseaseSurgery# !rauma

$alignancy

Heart ailure%ecent $I

Paralysis o lowerlimb

Inection

Infammatory boweldisease

&ephrotic syndrome

Polycythaemia

Paraproteinaemia

P&H'eh(et)s disease

Homocystinaemia

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 !hrombophiliaCongenital

 e*ciency o anti-thrombin III# protein +

or protein S

Antiphospholipidantibody or lupusanticoagulant

,actor V eiden genedeect or activatedprotein + resistance

ys*brinogenaemias

Acquired

Antiphospholipidantibody or lupusanticoagulant

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+linical eaturesPain and swelling o

cal 

%edness

"ngorged super*cialveins

 cramp in the lower

cal that persists or

several days and

becomes moreuncomortable as time

progresses.

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Pittng edema

ilated veins

Sti/ cal !ender vein course

Homans sign

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+linical eaturesFeatures of PE

 $assive - yspnea# syncope# hypotension#

cyanosissmall - situated distally near the pleura-

pleuritic pain# cough# or hemoptysis

0classic0 signs- tachycardia# low-grade ever#

nec1 vein distention# and an accentuated P 2

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Venous gangrene

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%uptured ba1er)s cyst#

+al muscle haematoma# %uptured plantaris muscle#

 !hrombosed popliteal aneurysm

 Arterial ischemia

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 Diagnosis

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Clinical variable Score

Active cancer 3Paralysis # paresis# recent cast 3

'edridden or4 5 days # ma6or surgery

7 32 wee1s

3

!enderness along deep veindistribution

3

"ntire leg swelling 3

8nilateral cal swelling 45 cm 3

Pitting edema 3

+ollateral super*cial non varicose veins 3

Alternate dia nosis at least li1el as -2 9: # $ 3#2 H;5

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Venous 8S<3 ac1 o vein compressibility=principal>

Absence o ?win1@ on crosssection

,ailure to oppose walls dueto passive distension

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2 !hrombus

homogenous # lowechogenecity

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5 +al compression blunts

doppler fow signal

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Management

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ProphylaisLow B young# minor illness # operations

lasting 75:

Moderate B 4 C: or with a debilitating illnesswho are to undergo ma6or surgery.

igh B 3> 4C: who have seriousaccompanying medical conditions= +VA $I>#

  2>ma6or surgery with an additional ris1actor =past history o venousthromboembolism or 1nown malignantdisease.>

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High-ris1 general surgery-$ini-8,H or  $EH

 !horacic surgery- $ini-8,H FIP+

 +ancer surgery - $EH#consider 3 month oprophylais

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  !otal hip replacement#

total 1nee replacement# hipracture - $EH#ondaparinu

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&eurosurgery - IP+

&eurosurgery or brain tumor-$ini-8,H or  $EH# F IP+ Fpredischarge venous

ultrasonography $edically ill patients- $ini-8,H or  $EH

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Anticoagulationcontraindicated - IP+

ong-haul air travel - $EHor very high-ris1 patients

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 !reatment G

anticoagulationInitiation G 8,H # $EH #ondaparinu

Proven HI! G direct thrombininhibitor G agatroban #

lepirudin # bivalirudin$aintenance G wararin

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AP!! G 2 -5

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iv bolus - :::-3:::: 8

ollowed by inusion 3:::-3::8hr

Short t J

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<reater bio availability #

predictable # longer tJ"noaparin

alteparin

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,ondaparinu G anti Ka

pentasaccharide&o lab monitoring no HI!

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Eararin

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Initiated in mg dose

 !arget I&% 2. =2-5>

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urationP" ater surgery# trauma#

or estrogen eposure-have a low rate orecurrence ater 5GLmonths oanticoagulation.

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 V! isolated to an upperetremity or cal that has been

provo1ed by surgery# trauma#estrogen# or an indwelling centralvenous catheter or pacema1er- 5

months o anticoagulationsuMces.

 ,or provo1ed proimal leg V!

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 cancer and V!"# 5GL monthso $EH as monotherapywithout wararin and tocontinue anticoagulation

inde*nitely unless the patientis rendered cancer-ree.

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 Idiopathic# unprovo1ed

V!"# =incl long-haul airtravel> anticoagulationor an inde*nite durationwith a target I&% between2 and 5

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.moderate or high levels oanticardiolipin antibodies -inde*nite-durationanticoagulation even i the

initial V!" was provo1ed bytrauma

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,ibrinolysis

rtPA

Iliac vein thrombosis

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IV+ *lters

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Active bleeding

%ecurrent venousthrombosis despiteanticoagulation